<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/11/2021
Date Signed: 09/11/2021 08:51:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 43DATE:
09/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Savanah Rios, Medication TechnicianTIME COMPLETED:
09:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/11/21 at 7:30am to conduct a health and safety check on the residents. LPA met with Savanah Rios, Medication Technician and stated the purpose of the visit.

LPA and Caregivers Christina Gonzalez and Candice Outlaw toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.
The facility is licensed for a capacity of 68 non ambulatory of which 6 may be bedridden. Facility has a Hospice Waiver for 15. Currently, there are 10 residents receiving hospice services at this time. LPA observed a random amount of residents in their rooms.
LPA observed there are 5 caregivers, 1 Housekeeper, 1 Cook, and 1 Medication Technician working during this visit. 3 caregivers are from a staffing agency and are not associated to the facility. The facility was cited for not associating agency staff twice. The most recent citation was on 9/10/21. The plan of correction is due 9/13/21. Due to todays findings that there are 3 agency staff working without being associated, the facility will not be cited today to allow time to clear the previous citations and to associate any new persons including those coming to work from any agency.
LPA observed 2 day perishables and 7 day non-perishables food items. LPA observed breakfast being prepared which includes scrambled eggs, donuts, bacon, danish, and watermelon.
The hot water measured at 105.0*F which is within the required range of 105-120*F.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The medication technician was pouring medications during the time of the visit.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. Exit interview held. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1